Clinical Care and Health Disparities STARFIELD, B; GERVAS, J; MANGIN, D
Annual review of public health,
04/2012, Volume:
33, Issue:
1
Journal Article
Peer reviewed
Open access
Health disparities, also known as health inequities, are systematic and potentially remediable differences in one or more aspects of health across population groups defined socially, economically, ...demographically, or geographically. This topic has been the subject of research stretching back at least decades. Reports and studies have delved into how inequities develop in different societies and, with particular regard to health services, in access to and financing of health systems. In this review, we consider empirical studies from the United States and elsewhere, and we focus on how one aspect of health systems, clinical care, contributes to maintaining systematic differences in health across population groups characterized by social disadvantage. We consider inequities in clinical care and the policies that influence them. We develop a framework for considering the structural and behavioral components of clinical care and review the existing literature for evidence that is likely to be generalizable across health systems over time. Starting with the assumption that health services, as one aspect of social services, ought to enhance equity in health care, we conclude with a discussion of threats to that role and what might be done about them.
Over time, the definition of prevention has expanded so that its meaning in the context of health services is now unclear. As risk factors are increasingly considered to be the equivalent of ...“diseases” for purposes of intervention, the concept of prevention has lost all practical meaning. This paper reviews the inconsistencies in its utility, and suggests principles that it should follow in the future: a population orientation with explicit consideration of attributable risk, the setting of priorities based on reduction in illness and avoidance of adverse effects, and the imperative to reduce inequities in health.
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BFBNIB, CMK, NMLJ, NUK, PNG, SAZU, UL, UM, UPUK
The effect of silicon (Si) supplement on preventing bone mass loss induced by ovariectomy (OVX) in rats was investigated. Three groups of 15, 100-day-old female Wistar rats each, with a mean initial ...weight of approximately 260 g per animal, were selected for the present study. One of the experimental group consisting of 15 OVX rats was fed a diet supplemented with 500 mg of Si per kg of feed (Si + OVX). The other two groups consisting of 15 OVX and 15 sham-OVX rats did not receive these supplements. Morphometric (weight and length) and densitometric studies with dual-energy X-ray absorptiometry were performed on the whole femur and 5th lumbar vertebra of each animal 30 days after the experiment. The Si + OVX rats did not show a loss of bone mass induced by OVX at axial level (5th lumbar vertebra) or periphery (femur). Nonetheless, a significant increase (ANOVA with Bonferroni/Dunn post hocs test) of longitudinal development of the femur (P < 0.0001) was patent. These results, obtained through the measurements of axial and peripheral bones, warrant closer scrutiny in connection with the Si inhibitory effect on bone mass loss as well as the stimulatory effect on bone formation. Both actions, namely, inhibition of resorption and stimulation of formation, infer that Si may have a potential therapeutic application in the treatment of involutive osteoporosis.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
To make feasible and practical proposals to improve equality in the course of clinical care during the patient-provider encounter.
Design: A focus group study was conducted with a qualitative ...approach from the perspective of reducing health inequalities in the clinic. Setting: A classroom discussion focused on equality in clinical work. Subjects: 98 professionals from several countries. Measurement tools: An analysis of the responses was performed, grouped by themes interpreted by analysts, and restructured to provide consistency and uniformity to responses given. Data were collected using a questionnaire with open answers, allowing free-form answers to three general questions that addressed improving equality from the perspective of the professional themselves, patients, and health policy managers. No saturation horizon of analytical discourses was set, to understand that from this subjective prioritization of opinion there is no possibility that discourses reached saturation.
Responses were added to the 3 principal axes, recommending that professionals be aware of their discriminatory ability. Patients were asked to trust their health professionals and that they should be assigned to a professional. It was also proposed that managers provide information systems, help reduce health inequalities, and encourage professional freedom.
The paper presents concrete measures to promote improved equality in clinics during the delivery of health care.
El objetivo de este trabajo es analizar el contenido y calidad de los comentarios incluidos en el Boletín Bibliográfico CESCA, así como su utilidad para los suscriptores del mismo. Se realiza un ...estudio descriptivo de lo publicado en 1991 y se analizan las respuestas a una encuesta remitida a los suscriptores. Los artículos de revistas constituyeron el 92 % de todos los comentarios; se utilizaron 90 revistas distintas; 13 revistas concentran el 55 % del total de los comentarios. La temática más frecuente de los documentos comentados fue la clínica (39 %), seguida de la investigación de servicios sanitarios (29 %). Se ha encontrado un 5 % de errores. Los suscriptores emplearon el Boletín como alerta bibliográfica y como soporte de formación continuada. Así pues, el Boletín Bibliográfico CESCA, que comenta y califica los documentos, es una ayuda para los lectores, tanto en alerta bibliográfica como en formación continuada.
La actividad clínica tiene más ventajas que inconvenientes, lo que justifica su realización, y su aprecio social. Sin embargo, con el curso de los años y el desarrollo tecnológico, están disminuyendo ...el umbral para la intervención médica, y el margen entre beneficios y riesgos. Cada vez se atiende a más pacientes con mayor intensidad de recursos preventivos y curatives (de diagnóstico y de tratamiento), y en lugares inapropiados (donde se concentran esos recursos). Todo ello aumenta la probabilidad del daño innecesario por consecuencia de la actividad sanitaria. Es decir, disminuye lo que llamamos «seguridad del paciente».
No basta con ofrecer servicios de calidad a quienes los necesitan, pues hay que conseguir, también, ofrecer cantidad en el lugar oportuno. Así, la actividad médica debería ofrecer cuidados de «baja intensidad y gran calidad», con una actitud activa continua que evite los daños por esas actividades, necesarias o innecesarias (prevención cuaternaria).
En este trabajo se consideran cuatro ejemplos de la necesidad de aplicar prevención cuaternaria en España:
1) la prevención cardiovascular (donde se hace de más a quienes no lo necesitan, y de menos a los que lo precisan),
2) el uso de los nuevos antidepresivos (que ha provocado una «epidemia» de depresiones, de incierto diagnóstico),
3) el uso de antibióticos (muchas veces innecesario, con el consiguiente aumento no justificado de las resistencias bacterianas), y
4) el diagnóstico genético (con el ejemplo de la promoción del cribado de la hemocromatosis, de dudoso valor científico, pero indudable efecto en la medicalización de la sociedad).
Medical activities have more positive than negative outcomes. Because this balance, medicine has a great social recognition. But with new technology and more agressive diagnostic and therapeutic interventions, there is a decreasing gap in between benefits and harms. Risk increases because more interventions, and because placing patients in more technology environments. As a consecuence, patient safety decreases.
Quantity becomes as important as quality, and the place of care is crucial for patient safety. Medical activities should be of «low intensity and high quality», performed in the low level of care possible. Then, quaternary prevention (to avoid unnecessary use and risk of medical interventions) should be a continous parallel clinical activity.
I consider four examples of needed quaternary prevention, with Spanish data: 1) cardiovascular prevention (where there is an inverse use of resources, as patients who need more receive less); 2) use of new antidepresants (which has provoke an artificial epidemic of «depression”); 3) use of antibiotics (frequently, unnecessary use), and 4) genetic diagnosis (with the example of screening of haemochromatosis, and a commentary about genetics and medicalisation).
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Resumen Las fronteras entre niveles sanitarios son artificiales, pues se deben más a la organización de los servicios que a las necesidades de los pacientes. Pero, puesto que existen, lo lógico es ...que la coordinación entre niveles logre superarlas para ofrecer los servicios que precisan los enfermos. La gestión de casos (pacientes en situaciones peculiares, como el alta hospitalaria) y la gestión de enfermedades (pacientes con alguna enfermedad, como la diabetes mellitus) tratan de dar respuesta a los problemas de coordinación, ya sea mediante la mejora de la estructura «natural» o una superestructura que se añade a los cuidados habituales. Son enormes el brillo y el atractivo de la gestión de casos y enfermedades, pero las pruebas científicas a su favor son débiles o inexistentes, tanto en lo que se refiere al impacto en salud como a su coste. Los programas de gestión de casos/enfermedades son respuestas verticales que debilitan la estructura horizontal que tenemos en España, la atención primaria. La necesidad de estos programas debería servir para justificar aún más el desarrollo de una reforma procoordinación de la atención primaria, que traslade poder, responsabilidad y autonomía al médico de cabecera, de forma que pueda coordinar los servicios clínicos y sociales que precisan los pacientes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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